3-Steps Self-Monitoring Checklist

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					         3-Steps Self-Monitoring Checklist                               3-Steps Self-Monitoring Checklist

Name: _____________________________ Date: _____                 Name: _____________________________ Date: _____

Step 1- Before Class:                                           Step 1- Before Class:
1. Do I have my materials and homework ready?     Yes No        1. Do I have my materials and homework ready?     Yes No
2. Did I listen to directions?                    Yes No        2. Did I listen to directions?                    Yes No
3. Did I get started on time?                     Yes No        3. Did I get started on time?                     Yes No
Step 2- During Class:                                           Step 2- During Class:
Am I working? ( Check the clock every 5 minutes and circle)     Am I working? ( Check the clock every 5 minutes and circle)
                  Yes if on-task      No if off-task                              Yes if on-task      No if off-task
Yes   Yes    Yes   Yes   Yes   Yes   Yes   Yes      Yes   Yes   Yes   Yes    Yes   Yes   Yes   Yes   Yes   Yes      Yes   Yes
no    no     no    no    no    no    no    no       no    no    no    no     no    no    no    no    no    no       no    no
Step 3- After Class:                                            Step 3- After Class:
4. Did I self-monitor to stay on task?           Yes No         4. Did I self-monitor to stay on task?           Yes No
5. DID I follow directions?                      Yes No         5. DID I follow directions?                      Yes No
6. Did I work on the task for the entire time?   Yes No         6. Did I work on the task for the entire time?   Yes No
7. DO I have homework tonight?                   Yes No         7. DO I have homework tonight?                   Yes No
My overall behavior in this class:                              My overall behavior in this class:
(my rating)     1        2         3         4       5          (my rating)     1        2         3         4       5
              Poor     NI         OK        Good   Great                      Poor     NI         OK        Good   Great

My overall behavior in this class:                              My overall behavior in this class:
(teacher rating)     1        2     3         4        5        (teacher rating)     1        2     3         4        5
                   Poor      NI     OK       Good     Great                        Poor      NI     OK       Good     Great
To be completed by teacher:                                     To be completed by teacher:
       Form Complete= 5 points                                         Form Complete= 5 points
Teacher rating of 4 or 5 = 5 points                             Teacher rating of 4 or 5 = 5 points
             Total Points= ________                                          Total Points= ________

				
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